James Glover II / Star staff
"I wish I had done it a long time ago," said Dr. Edward Portnoy, a Westlake Village internal medicine physician who once had a practice of about 2,800 patients. Now he sees about 380 people but takes home about the same profit, thanks to the $1,800 each patient pays yearly.

Spend more time caring for patients. Make more money. Leverage insurance companies further out of the picture.

The formula can seem like a cancer cure to doctors battling the malignant one-two punch of cuts in insurance reimbursements and the need to see more patients to earn the same income. Alternatives to insurance-based medicine carry special allure in Ventura County where doctors are fighting Blue Cross over a new fee schedule.

At least two primary care practices already charge patients annual membership fees in a system called concierge care. Other doctors insist people dole out money up front and deal with insurance companies on their own.

More are considering those options, though some in healthcare worry that less reliance on insurance means patients pay more, tilting the best care away from people who aren't rolling in money.

"I wish I had done it a long time ago," said Dr. Edward Portnoy, a Westlake Village internal medicine physician who once had a practice of about 2,800 patients. Now he sees about 380 people but takes home about the same profit, thanks to the $1,800 each patient pays yearly.

He works the same amount of hours but spends roughly twice the time with each patient. He has more time to do intensive physicals and help patients stay healthy, rather than running from one crisis to the next like a war surgeon doing meatball surgery.

"At the end of the day, I feel more like I'm not behind the eight ball," he said.

'For a well-to-do clientele'

At Dr. Stanley Frochtzwajg's family practice in Ventura, patients don't face annual fees but pay at the office for whatever services they receive. A routine office visit is about $80. They're given the paperwork to submit to their insurance companies. One patient said she ends up paying about 30 percent of the bill but is happy with her care and willing to pay for it.

The extra money buys more time with the doctor. And it means Frochtzwajg doesn't need authorizations from Blue Cross or anyone else before he decides what treatment is best for the patient.

"I don't want to be beholden to insurance companies," he said. "I want to be beholden to my patients."

"There's not a lot of people who can afford it," said Anthony Wright, executive director of the consumer advocacy group Health Access California. "The reason some people call it boutique medicine is that this is for a well-to-do clientele."

Wright believes the current insurance system is broken as shown by the about 4.9 million Californians who are uninsured. But he doesn't think systems that shift more burden onto the patients are the answer or will evolve into more than an isolated alternative.

"Why would the vast majority of people who have coverage and want coverage, why would they want to pay more money?" he asked, noting patients in some practices also inherit the hassle of negotiating with the insurance companies. "The trend of boutique medicine sends the consumers in the direction of you're on your own. Everyone for themselves."

But Carol Miller of Thousand Oaks thinks the $3,600 she and her husband pay in annual fees to see Portnoy is worth it because it brings peace of mind. The money covers an annual physical and a battery of screenings for everything from Alzheimer's to sleep apnea. The fee also covers follow-up that focuses on preventive care.

There are other perks. People in Portnoy's waiting room find a basket filled with Cliff bars, crunchy peanut butter and chocolate chip bars. They're served tea or Snapple.

They don't have much time in the waiting room because it's usually empty. They go right in to see the doctor.

Patients are given wallet-sized CDs bearing their medical histories. They're promised same-day appointments, sometimes within 45 minutes. If they have problems, they're given the doctor's cell phone number.

"You don't get that with a regular doctor. They don't give out private numbers," Miller said. "I feel like he's more than a doctor. With this kind of practice, they know our name. I call on the phone and they say Hi, Carol, how are you doing today?' "

Portnoy and Paul Block, a Thousand Oaks internist, belong to a national network of about 160 boutique doctors administered by a Florida company called MDVIP. The company is also in discussions with three or four other doctors in Ventura County, said MDVIP President Darin Engelhardt.

Because doctors in the network stress preventive care, patients spend as much as 80 percent less time in the hospital, Engelhardt said.

"Long term, unequivocally, this program reduces healthcare costs," he said.

Frochtzwajg wouldn't join a network like MDVIP because he thinks many of his patients couldn't pay $1,800 in annual fees. His program of asking people to pay instead of insurance companies also means they pay more, but the increase isn't as dramatic.

Shortage of family doctors

Though doctors like Portnoy limit their practices to no more than 600 patients, Frochtzwajg cares for about 2,500 people. That's still less than many other doctors because he can charge his patients more than what insurance companies would pay him. He also saves money on the office staff needed to process insurance claims.

He's not doing anything new. In a 27-year career, Frochtzwajg has never contracted with insurance companies and hopes he never will.

"Your patient is the focus. You serve the patient and the insurance intermediary doesn't call the shots," he said.

The words are attractive in a county where many specialists say they are considering terminating their Blue Cross contracts because of a new fee schedule that threatens their ability to stay in business. Many will keep their other insurance contracts but will ask Blue Cross patients to pay their own way.

The situation of primary care doctors may be more unstable. Though their reimbursements could rise, they often make less than specialists and often have to see more patients, which means less care and longer waits.

"It's not uncommon for patients to bring a copy of War and Peace' when they go for a doctor's appointment," said Engelhardt of MDVIP.

More troubling, there's an emerging shortage. About 14 percent of medical school graduates chose family medicine in 2000, according to the American College of Physicians. Five years later, that number dropped to 8 percent.

Dr. Ted Hole, a Ventura family physician, thinks the one way to survive is for doctors to lessen their reliance on insurance reimbursement. He is considering terminating some of his insurance contracts and asking his patients to pay upfront.

"I think that's the direction that a lot of primary care physicians are going to need to go in," he said. "There's only so much you can do. I don't think you can see 50 patients a day and deliver first-class medical care."

Dr. Bob Gonzalez, medical director at Ventura County Medical Center, worries that less reliance on insurance means fewer people getting healthcare. They won't be able to afford it.

The specter of more doctors downsizing their practices and seeing fewer patients also alarms Gonzalez. It means patients won't be able to find any doctors or could be dumped on an already overburdened doctor.

So yes, he said, more money, less insurance and more time with patients may be good for individual doctors.

"But whether it's good for society or good for patients is the overall question," he said.